Journal of Medicinal Plants Research Vol. 5(24), pp.

5649-5657, 30 October, 2011

Available online at http://www.academicjournals.org/JMPR
ISSN 1996-0875 ©2011 Academic Journals

Review

Sinusitis review
Sajid Khan, Abdul Hannan, Khan Usmanghani, Shahab Uddin, Halima Nazar, E. Mohiuddin
and M. Akram*
Faculty of Eastern Medicine, Hamdard University, Karachi, Pakistan.
Accepted 22 September, 2011

Sinusitis is one of the most common health care complaints in all over the world. Approximately, one in
eight people in the world will have sinusitis at one time in their lives. The treatment of sinusitis is
difficult. The drastic negative effect of sinusitis on patients’ quality of life has been generally
underappreciated and unrecognized. Recent studies show that patients score the effects of chronic
sinus disease in areas such as bodily pain and social functioning as more debilitating than diseases
such as angina, congestive heart failure, emphysema, chronic bronchitis, and lower back pain, to name
a few. In the past, treatment of sinusitis was not available and people affected by sinusitis had to live
with their sinus problem. The diagnosis is based primarily on clinical signs and symptoms. However,
there have been enormous advances in the past 15 years in the ability to diagnose and treat these
problems. This is largely because of technological advances in nasal endoscopy and X-ray imaging.
Also, the development of newer, more powerful medications and significant advances in surgical
treatment have played a major role in improved patient care.

Key words: Sinusitis, nasal endoscopy, x-ray imaging.

INTRODUCTION

Sinusitis is swollen or infected linings of the sinuses. The
sinuses are hollow spaces in the bones of your face and
skull. They connect with the nose through small
openings. Like the nose, they are lined with membranes
that make mucus. More than 37 million people are
afflicted with sinusitis each year, making it one of the
most common health conditions. That number could be
increased significantly higher, since the symptoms of
bacterial sinusitis often mimic those of colds or allergies,
and many people usually do not prefer to consult a doctor
for proper diagnosis and treatment with an antibiotic.
Approximately 90% of patients will visit their primary care
clinics for the treatment of sinusitis. Therefore, it is
expected that primary care physicians should be attentive
to this condition because its incidence appears to be on
the rise. Antimicrobial resistance patterns have changed
to create increasingly complicated problems with
antimicrobial therapy while treating the cases of sinusitis
(Vincent, 2005). Sinusitis is a common ailment wherein
16% of the population reports a diagnosis of sinusitis
annually. It is said that sinusitis is a costly disorder and
*Corresponding author. E-mail: makram0451@gmail.com. Tel:
92-021-6440083. Fax: 92-021-6440079.
that huge finance are spent annually on medications to
treat nasal and sinus problems. The national ambulatory
medical care survey (NAMCS) lists sinusitis as the fifth
most common diagnosis for which an antibiotic is
prescribed. There are many problems in diagnosing
acute bacterial sinusitis; one being overlaps with other
upper respiratory tract diagnoses such as allergies, viral
infections, idiopathic rhinitis, fungal disease, neoplastic
processes. The emergence of resistance and variable
antibiotic susceptibilities of causative bacteria poses a
greater challenge to antibiotic selection. Because
sinusitis significantly impacts quality of life, therefore, the
trends in diagnosis and treatment of the acute condition
for sinusitis should be executed (McCain et al., 1995).
The purpose of this study is to highlight clinicopathologic
features and treatment of sinusitis.
SINUSITIS
Sinusitis is the medical term for inflammation (irritation
and swelling) of the sinuses. It is usually caused by
infection. The sinuses are the moist air spaces located
within the bones of the face around the nose. The frontal
sinuses are located in the area near the eyebrows; the
maxillary sinuses are located inside the cheekbones; the
5650 J. Med. Plants Res.
Table 1. Factors predisposing to sinusitis.
S/N Factors predisposing to sinusitis
1 Prior upper respiratory tract infection
2 Concurrent group A streptococcal infection
3 Allergic rhinitis
4 Environmental pollutants (smoke)
5 Dental infections or extractions
6 Hormonal changes
7 Iatrogenic factors (mechanical ventilation, nasogastric tubes, nasal packing, dental procedures)
8 Anatomic variations (tonsillar and adenoid hypertrophy, deviated septum, nasal polyps, cleft palate)
9 Swimming
10 Immunodeficiency
11 Secretory disturbances (cystic fibrosis)
12 Immotile cilia syndrome
13 Abnormal mucociliary clearance secondary to ciliary structural abnormalities (Kartagener’s syndrome)
14 Bronchiectasis
15 Asthma or acetylsalicylic acid–asthma–polyposis triad
16 Immature immune system
17 Adenoidal hypertrophy
ethmoid sinuses are between the eyes; and the sphenoid
sinuses placed behind the ethmoid sinuses. A healthy,
person sinuses are filled with air, making the facial bones
less dense and much lighter in weight. If there are no
sinuses, the skull would be very much heavier and in this
condition, head will have to prop up with hands, all day
sinuses also play a role in how our voices sound.
The sinusitis can be caused by viruses or bacteria as
well as a combination of both. Generally, when a person
catches cold, he exhibits inflammation of the sinuses,
known as viral sinusitis. Allergies could be one of the
factors that lead a person to develop sinusitis.
When the nasal congestion (stuffiness), associated with
common cold or allergies, hinders the sinuses to drain
properly, then in such condition bacteria can become
trapped inside the sinuses, thus leading to development
of bacterial sinusitis (Wald, 1999).
PATHOPHYSIOLOGY
Sinusitis encompasses a spectrum of acute and chronic,
neutrophilic and eosinophilic, nonallergic and allergic
inflammatory processes. Bacterial sinusitis is an
inflammation of the paranasal sinus mucosa caused by
bacterial overgrowth in a closed cavity. This disorder is
also referred to as rhinosinusitis, because the nasal
epithelium is continuous with the mucosa that lines the
paranasal sinuses and the disease can affect both sites.
Viral or allergic rhinitis typically precedes sinusitis, and
sinusitis without rhinitis is rare in its occurrence. Many
factors play a role to predispose an individual to sinusitis
(Table 1). Recent evidence shows that viral upper
respiratory tract infections (Upper respiratory tract
infection) and pharyngeal colonization with group A
streptococci predispose children to acute bacterial
sinusitis. It may be appropriate to select antibiotics that
are also effective against group A streptococci because
Streptococcus pyogenes may be a concurrent infection in
15 to 20% of children.
The maxillary, frontal, ethmoid, and sphenoid sinuses
all drain into the nasal cavity through the ostia, which are
approximately 1 to 3 mm in diameter (Figure 1).
Obstruction of this narrow space may set up an
environment for bacterial pathogens to colonize
(Zacharisen and Kelly, 1998).
Antibiotic prescription for acute obstruction is generally
not indicated; however, if the obstruction persists for 7 to
10 days, secondary bacterial infection could be the cause
of the malaise. Usually acute bacterial sinusitis, a single
bacterial species is responsible for the infection;
however, multiple bacterial isolates were cultured in 26
and 30% of cases has been communicated in two
different studies, respectively.
In addition to obstruction caused by inflammatory
edema of the mucosa, viral and bacterial inflammation
also decreases mucociliary activity, further compromising
natural host defenses. Impaired ciliary transport results in
stagnation of secretions, decreased pH, and lowered
oxygen tension, providing a perfect medium for bacterial
multiplication.
Sinusitis is classified on the basis of duration of
symptoms and anatomic location. Acute sinusitis
symptoms last as long as 4 weeks. Subacute sinusitis
has minimal to moderate symptoms that are present for 4
to 12 weeks. Chronic sinusitis persists for more than

Figure 1. Diagram of paranasal sinuses.
12 weeks and often has a pathophysiology that differs
from that of acute sinusitis. Chronic sinusitis represents
an ongoing inflammation characterized by eosinophilia.
The inciting agents of chronic sinusitis have been difficult
to identify or prove. Repeated damage of the mucosa in
this condition causes loss of the normal state of sterility.
Recurrent sinusitis is defined as 4 or more episodes in 1
year, each episode lasting more than 7 days, with
complete resolution between episodes.
The pathophysiology of sinusitis in children may figure
slightly different. The ethmoid and maxillary sinuses are
present and clinically significant at birth; however, the
other sinuses develop more slowly. The sphenoid sinus
develops between 3 and 7 years of age, and the frontal
sinuses develop by 12 years of age.
The sinuses continue to develop during childhood and
adolescence. In addition, the immune system is immature
in children, making host reduction of bacterial load more
difficult. There is a lack of agreement about the clinical
definition of sinusitis in children (Jones, 1999)
EPIDEMIOLOGY, PREVALENCE AND ECONOMICS
OF SINUSITIS
Each year, approximately 16% of adults receive
diagnoses of sinusitis. The incidence of sinusitis is higher
in the humid and colder regions as compared with the
moderate and hot areas. Rates of sinusitis are higher in
the fall, winter, and spring months. It is estimated that 1 in
5 people has symptoms related to sinus disease and
nasal allergies but in such situation the medical approach
is rather avoided and people rely in self treating the
Khan et al. 5651
condition. For the fact that many individuals do not
consult doctors for medical help for this condition, the
actual number of individuals affected may be much
higher. Those who seek treatment account for an
estimated 16 million office visits per year. The national
ambulatory medical care survey found sinusitis to be the
fifth leading diagnosis for which providers prescribed an
antibiotic.
For the fact that nasal symptoms are some of the most
common complaints brought to primary care physicians,
patients need to be informed that nonbacterial causes are
most often the basis for symptoms such as rhinitis, nasal
congestion, facial pressure, headaches, and postnasal
discharge. Acute viral upper respiratory tract infection,
seasonal allergic rhinitis, perennial allergic rhinitis,
vasomotor rhinitis and rhinitis medicamentosa have
symptoms that overlap with acute bacterial sinusitis and
are often a cause for misdiagnosis. Physician compliance
with patients’ expectation of an antibiotic can result in
indiscriminate antibiotic use. Studies show that 18 to 60%
of patients with colds are prescribed antibiotics. A survey
has shown that approximately 50% of antibiotics were not
indicated on the basis of evidence-based guidelines.
However, studies of overprescribing may not have
considered antibiotic use for prophylactic therapy,
severity of illness, follow-up arrangements, or patient
income variables.
Viral rhinosinusitis is a more likely cause of nasal
symptoms than any bacterial origin. Viral rhinosinusitis
occurs more often than bacterial sinusitis and does not
require antibiotic treatment. Although allergic rhinitis may
be a predisposing factor in bacterial rhinosinusitis, it has
not been clearly shown to cause bacterial rhinosinusitis in
5652 J. Med. Plants Res.
Percentage resistance to penicillin
Year reported
Figure 2. Increasing trend in Streptococcus pneumoniae penicillin resistance. Resistance is defined as
either intermediateresistance (minimal inhibitory concentration of ≥0.12 µg/mL) or high resistance
(minimal inhibitory concentration of ≥2 µg/mL).
adults, and there is only a slight correlation in children.
Rhinosinusitis in children is a multifactorial disease. As
the child becomes older, several predisposing factors
change. About 10 to 20% of children actually have
allergic rhinitis, which may be present all year. Children 2
to 5 years of age average 6 to 8 upper respiratory tract
infection per year. Approximately 5 to 10% of these upper
respiratory tract infections may become complicated by
acute bacterial sinusitis. Children in day-care centers
have more frequent and longer-lasting respiratory tract
infections because of superinfection. Anatomic variations
in children typically do not contribute to the prevalence of
pediatric sinusitis (McCaig and Hughes, 1995).
PATHOGENS IN SINUSITIS
The causative organisms of acute bacterial sinusitis are
similar to those of acute otitis media. They include
Streptococcus pneumoniae (30 to 40% of clinical
isolates), Haemophilus influenzae (20 to 30%), Moraxella
catarrhalis (12 to 20%), and Streptococcus pyogenes (up
to 3%). Other pathogens, found less frequently, include
other Streptococcus species, Staphylococcus aureus,
Neisseria species, and gram-positive and other gram-
negative bacilli.
Fungi are most commonly observed in
immunocompromised and diabetic individuals. Anaerobic
infections may occur in chronic sinusitis or with dental
disease. Clinical studies in children with sinusitis are rare,
because of the difficulties in diagnosing sinusitis in this
age group. In the few pediatric studies published, the
pathogens cultured from children with acute sinusitis and
subacute sinusitis are similar to those of adults. The
predominant pathogens isolated from pediatric patients
with chronic sinusitis are S. pneumoniae, M. catarrhalis,
H. influenzae, and anaerobes (Wang et al., 1999).
ANTIBIOTIC RESISTANCE
The incidence of the bacterial species causing sinusitis
has not changed in more than 4 decades; however,
antimicrobial susceptibilities have changed within the
past twenty years. Before 1980, more than 99% of
pneumococcal strains were susceptible to penicillin.
Recently, the prevalence of penicillin-resistant
pneumococci has increased dramatically worldwide and
shows a nearly twofold regional variation, approaching 33
to 58% of clinical isolates. Data from a surveillance
studies showed a 4% resistance rate in the 1980s, which
increased to 37% in 1997 (Figure 2).
At least one third of H. influenzae isolates and the
majority of M. catarrhalis isolates are β-lactamase–

producing. Before 1972, H. influenzae was almost
uniformly susceptible to ampicillin. Since then, β-
lactamase–producing strains resistant to ampicillin
represent 30 to 40% of isolates. M. catarrhalis was once
uniformly susceptible to all agents, but is now commonly
resistant. The overuse of antibiotics, inappropriate
dosing, and the use of broad-spectrum antibiotics as first
line treatment have contributed to the rising incidence of
drug-resistant strains of bacteria. Resistance will continue
to emerge and make our first-line agents less useful.
Some penicillin-resistant strains display multidrug
resistance to trimethoprim-sulfamethoxazole (TMP-SMX),
macrolides, and some cephalosporins.It is difficult to
predict emerging resistance patterns. Antibiotic use in
children is possibly a factor in emerging resistance,
especially in day-care settings. Several studies have
shown that there are substantial rates of multidrug-
resistant pneumococci among children in day-care
settings.
Currently, it is estimated that greater than 50% of
pneumococcal isolates from children in rural and urban
day-care settings are resistant to penicillin. It is important
for physicians to know the resistance patterns in their
specific community. Four percent to 48% of S.
pneumoniae isolates are resistant to penicillin, depending
on geographical area. Geographical resistance patterns
of S. pneumoniae, H. influenzae, and M. catarrhalis, the
three most common upper respiratory tract pathogens (a
total of 4,979 clinical isolates), were studied in 52
independent and hospital laboratories from September
1998 to February 1999. Approximately, one fourth of the
S. pneumonia isolates tested against penicillin were
resistant.
In the affluent regions, penicillin resistance rates were
significantly lower. The rates of erythromycin resistance
were similar to the rates of penicillin resistance. Although,
high resistance rates were noted across the country,
significantly higher rates were noted in the Southeast.
Thirty-one percent of H. influenzae isolates produced β-
lactamase. Ten strains were β–negative and showed
intermediate resistance to ampicillin. H. influenzae
showed consistently high resistance rates to ampicillin
across all regions and showed lower resistance rates to
TMP-SMX, except in the Southeast. The resistance rates
and positive β-lactamase production were consistent and
alarmingly high across all regions, reaching 87 to 96% for
M. catarrhalis. There is a direct correlation between β-
lactamase production and the prior use of β-lactam
antibiotics. β-lactamase–producing bacteria and
penicillin- resistant S. pneumoniae appear to be more
prevalent in the winter months than in the summer and
fall months. In a study of the percentage of patients with
oropharyngeal colonization with β-lactamase–producing
organisms gradually increased from September to April
and slowly decreased from April to August. Fireman has
shown that the administration of some β-lactam
Khan et al. 5653
antibiotics select β-lactamase –producing organisms in
the respiratory tract. These organisms can spread within
a family setting to other household members.
Prophylactic use of amoxicillin also selects penicillin-
resistant organisms (Fireman, 1992).
INTERFERENCE PHENOMENON
The use of wide-spectrum antimicrobial agents may alter
the normal upper respiratory tract flora. The use of such
antibiotics may contribute to persistence of infection by
inhibiting the nonpathogenic organisms in the upper
respiratory tract that generally interfere with the growth of
potential pathogens. A comparative trial evaluated the
effect of amoxicillin-clavulanate and cefprozil on the
nasopharyngeal bacterial flora in children treated for
acute otitis media. Both agents were equally effective in
eradicating the pathogenic organisms S. pneumoniae, H.
influenzae, and M. catarrhalis. Therapy with amoxicillin-
clavulanate resulted in a significant decrease in the
number of interfering, nonpathogenic bacteria, and
cefprozil had only a minimal effect. The nonpathogenic
bacteria included β-hemolytic streptococci, Prevotella
melaninogenica, and Peptostreptococcus anaerobius.
The number of these interfering organisms was reduced
at the end of therapy, from 50 to 11 after amoxicillin –
clavulanate therapy, and from 50 to 42 after cefprozil
therapy (p < .001). However, longterm follow-up was not
performed in this study. The diagnostic factors predictive
of sinusitis are given subsequently (Willner et al., 1997).
DIAGNOSIS
Intranasal cultures are not indicative of the bacterial
origin of acute sinusitis. The diagnosis of acute sinusitis
is often difficult and is based on a careful, thorough
history and physical examination. Although, sinus
aspiration and culture is the “gold standard” of diagnosis,
the procedure is painful and may lead to iatrogenic
infection. The majority of patients who visit a primary care
physician for respiratory symptoms are likely to have a
viral rather than a bacterial cause of sinusitis.
Differentiating viral rhinosinusitis from bacterial sinusitis
is often difficult, because viral rhinosinusitis often
precedes bacterial sinusitis. In general, symptoms of
bacterial sinusitis worsen after 5 days, persist for at least
10 days, and are more severe than those of viral disease.
About 0.5% of upper respiratory tract infection progress
to sinusitis. However, viral symptoms that persist for
more than 7 days often establish an environment suitable
for the development of bacterial infections and may
predispose the patient to bacterial sinusitis.
The overall clinical impression is a more accurate
diagnostic predictor of sinusitis than any single diagnostic
5654 J. Med. Plants Res.
Table 2. Diagnostic factors predictive of sinusitis.
S/N Major factors
1 Facial pain or pressure (requires another major factor for diagnosis)
2 Facial congestion or fullness
3 Nasal obstruction
4 Nasal purulence or discolored postnasal discharge
5 Hyposmia or anosmia
6 Fever (acute sinusitis only)
7 Minor factors
8 Headache
9 Halitosis
10 Fatigue
11 Dental pain
12 Cough
13 Ear pain, pressure, or fullness
14 Fever (nonacute sinusitis)
15 Based on data from Lanza and Kennedy.
predictor. The diagnosis of acute sinusitis depends on the
presence of at least 2 major diagnostic factors or 1 major
factor and 2 minor factors (Table 2). The number of
diagnostic factors correlates with the likelihood that a
bacterial infection is present.
A retrospective analysis found that family practice
physicians relied on only 4 factors (sinus tenderness,
facial pressure, postnasal drainage, and discolored
postnasal drainage) to differentiate sinusitis from upper
respiratory tract infection. However, no particular sign or
symptom is sensitive and specific for sinusitis. Relying on
poor clinical predictors (that is, imprecise signs and
symptoms) has significant implications for antibiotic use.
Physicians need to evaluate and consider multiple
diagnostic factors in sinusitis. Willner et al., 1997 found
the 4 symptoms and signs associated with a computed
tomography (CT)–confirmed diagnosis of acute sinusitis
to be; (1) 2 phases in the illness history, (2) purulent
rhinorrhea, (3) purulent secretions in the cavum nasi, and
(4) an erythrocyte sedimentation rate greater than 10
mm. If 3 of these 4 signs and symptoms were present,
the diagnosis had a specificity of 81% and a sensitivity of
66%. Although, this sensitivity is higher than that of any
individual clinical finding, the specificity is lower than that
of maxillary edema (99%) or temperature greater than
38°C (89%) (Willner et al., 1997).
Other complaints that may increase the probability of
correctly diagnosing sinusitis include a recent prolonged
upper respiratory tract infection, a lack of response to
decongestants, nasal airway obstruction, facial pain and
pressure, sore throat, decreased sense of smell, and
edema of the eyelid or chemosis. In adults, purulent
postnasal discharge and facial pain over the affected
sinus that worsens with movement or percussion are
cardinal symptoms. Visualization of purulent nasal
drainage on examination may be a strong indicator of
acute sinusitis. However, purulence does not differentiate
between a viral origin and a bacterial origin.
Anterior rhinoscopy is very important and can be
performed with a nasal speculum or otoscope. The use of
a topical decongestant before the examination may
improve the field of view. The examination should include
viewing the turbinates and septum, evaluating the quality
of the mucus, and determining the presence of polyps
and bleeding. Symptoms in children are different from
those in adults and are difficult to distinguish from those
of the common cold or vasomotor rhinitis. They are more
nonspecific and may include rhinorrhea, nasal congestion
or obstruction, fever, purulent anterior or posterior nasal
discharge, snoring, mouth breathing, feeding problems,
bad breath, cough, and hyponasal speech. The most
common complaints are cough and nasal discharge. The
classic signs and symptoms found in adults (eg., facial
pain and headache) are rare. Pediatric acute sinusitis
must be differentiated from allergic rhinitis, which is
characterized by continuous stuffiness, sneezing, itchy
eyes, and a family history of atopy. Adenoidal
hypertrophy or a severely deviated nasal septum may
also contribute to symptoms. The presence of a foreign
body, asthma, or neoplasm must be ruled out.
Further diagnostic testing and imaging should be
performed for atypical cases and treatment failures. No
imaging studies are recommended for the routine
diagnosis of uncomplicated sinusitis presented to the
primary care physician. The diagnostic value of sinus
radiographs is limited by poor sensitivity and specificity.
Radiologic evidence of sinusitis is frequently found in
patients with viral rhinitis. The Waters’ view may offer the
simplest demonstration of fluid accumulation in the
maxillary sinus. Although, the presence of opacification or
 Khan et al. 5655

Table 3. Value of specific history, examination, and laboratory test parameters in initial diagnosis of acute sinusitis.

S/N Parameter importance

1 Patient history
“Cold” present for more than 7 to 10 days significantly important
Unusually severe upper respiratory tract complaints significantly important
Fever Significantly important
Mucopurulent discharge (>7 days) significantly important
Pain in upper teeth significantly important
Lack of response to over-the-counter decongestants significantly important
Dull headache Variable importance*

2 Clinical assessments
Unilateral or bilateral tenderness in midface region significantly important
Inspection of nasal mucosa significantly important
Facial tenderness significantly important
Intranasal pus significantly important
Purulent postnasal mucus in pharynx significantly important
Transillumination Not significantly important

3 Diagnostic tests
Radiographs (Waters’ view) Variable importance*
Radiographs (3 views) not significantly important
Sinus aspiration, when indicated significantly important
Computed tomography† Not significantly important
Anterior rhinoscopy significantly important
Ultrasound Not significantly important
Magnetic resonance imaging not significantly important
Fiberoptic nasal endoscopy Variable importance*
Nasal mucus smear not significantly important
Immunologic screen not significantly important
Cultures from sinus puncture (when indicated) significantly important
Erythrocyte sedimentation rate not significantly important
*Important only in context of other signs, symptoms, and patient history in whole picture of clinical assessment. †Chronic
infection or complications pending.

air-fluid levels in the sinuses is fairly predictive of
bacterial infection, it is seen in only 60% of patients with
acute sinusitis.
If mucosal thickening is included as an indication of
sinusitis, the specificity can be as low as 36%.
Researchers conclude that transillumination has limited
diagnostic use and depends on the clinician’s skill level.
As a single finding, transillumination cannot be relied on
to confirm or rule out the diagnosis. Ultrasound also has
limited diagnostic value. A CT scan should be reserved
for patients who respond inadequately to medical
therapy, have numerous bacterial infections throughout
the year, or have a history of polyposis. Most patients
with a viral upper respiratory tract infection who undergo
a CT scan will demonstrate evidence of sinusitis, and
therefore, the value of CT scanning in diagnosis is
questionable. However, CT scanning is useful in
identifying the underlying cause of chronic infection and
in identifying the sinuses involved and any complications
that may exist. The CT scans should be performed in a
coronal view, and a limited series is usually adequate.
Contrast enhancement is not recommended unless there
is a central nervous system complication. In Table 3 is
presented the value of specific history, examination, and
laboratory test parameters in the initial diagnosis of acute
sinusitis (Tinkleman and Silk, 1989).
ANTIMICROBIAL THERAPY
Although, 40% of sinusitis patients will recover
spontaneously, antibiotics are indicated in the treatment
of correctly diagnosed acute sinusitis. Sinusitis is treated
empirically because of the invasive nature of culturing the
5656 J. Med. Plants Res.

Table 4. Risk factors prompting use of second-line agent.

S/N Risk factors

1 Antibiotic use in past month
2 Resistance common in community
3 Failure of first-line agent
4 Infection in spite of prophylactic treatment
5 Smoker in family
6 Child in day-care facility
7 Younger than 2 years of age
8 Patient history
9 Allergy to penicillin or amoxicillin
10 Frontal or sphenoidal sinusitis
11 Complicated ethmoidal sinusitis
12 Presentation with protracted (>30 days) symptoms

paranasal sinuses. Comparative trials have shown
minimal evidence of the superiority of one antibacterial
agent over another. Effective antibiotic therapy often
produces a more rapid resolution of symptoms.
The goal of treatment is to arrest the acute infection
before it progresses and to prevent serious sequelae
(e.g., facial osteomyelitis, cavernous sinus thrombosis,
meningitis, orbital cellulitis or abscess, or brain abscess).
Most importantly, appropriate use of antibiotics may
decrease the rate of complications, as well as prevent the
progression of acute sinusitis to chronic sinusitis through
a more rapid reduction of tissue edema and bacterial
contamination and the reestablishment of drainage and
ventilation of the sinus cavity. Treatment is thought to
prevent permanent mucosal damage. Despite adequate
antibiotic treatment, the mortality rate (30%) and the
morbidity rate (60%) from cavernous sinus thrombosis
remain high in adults and slightly better in children.
Treatment of bacterial sinusitis usually begins with an
inexpensive first-line agent (e.g., amoxicillin or TMP-
SMX). A recent analysis of in vitro data suggests that
current doses of amoxicillin may not be adequate for
eradication of intermediately and fully resistant S.
pneumoniae. It is recommended that the amoxicillin dose
be doubled (up to 80 to 90 mg/kg per day; maximum of 3
g/d), especially in areas in which resistance to S.
pneumoniae is high. The clinical benefit of using higher
doses of amoxicillin still needs to be evaluated in clinical
trials. In many geographic areas, the resistance of S.
pneumoniae to TMPSMX is higher than that to penicillin.
Resistance of H. influenzae to TMP-SMX has increased
significantly in recent years. Second-line agents should
be used when resistant pathogens are suspected (Klapan
et al., 1999). The risk factors in treatment plan are listed
in Table 4.
Choosing a second-line antibiotic depends on proven
clinical efficacy, resistance patterns, dosing schedules,
the adverse events profile, the potential for compliance,
knowledge of patient allergies, the previous response
history, the physician’s experience with agents, and the
cost-benefit ratio. Antibiotic choice based on
pharmacokinetic properties alone may be misguided.
Although, the minimal inhibitory concentration (MIC) and
minimal bactericidal concentration (MBC) have been the
gold standards for measuring drug activity, they provide
only partial information.
The MIC and MBC are useful predictors of
drugorganism interaction in a static system, but they do
not provide information on the time course of microbial
exposure to an antibiotic. For β-lactam antibiotics,
vancomycin, clindamycin, and the macrolides, activity
depends on the time of exposure to the drug, at low
multiples of the MIC, rather than peak drug concentration.
In sinusitis treatment with β-lactam antibiotics (amoxicillin
and cephalosporins), time of exposure is critical. In
animal infection models, time above MIC has been the
only pharmacodynamic parameter to correlate with the
clinical efficacy of β- lactam antibiotics. A nationwide
surveillance study evaluating 4,489 clinical isolates of S.
pneumonia for their susceptibility to various antimicrobial
agents determined that penicillin susceptibility had a
significant impact on time above MIC. Plasma levels of
cefprozil, cefaclor, cefixime, cefpodoxime proxetil, and
cefuroxime axetil exceeded the geometric mean
moraxella catarrhalis (McAlister et al., 1989).
DURATION OF THERAPY
The symptoms should abate within a few days after the
initiation of treatment, and 10 to 14 days is considered an
adequate treatment interval. A longer treatment interval
may be warranted if symptoms persist. Although, shorter
courses of antimicrobial treatment to lower costs, reduce
side effects, increase compliance, reduce the potential for
resistance, and decrease the impact on commensal flora
have also been communicated. Although, the results of
these studies are promising, further studies of

short-course therapy are needed, especially in children,
and clinical judgment is paramount.
The majority of patients with sinusitis are treated on an
outpatient basis that necessitates appropriate follow-up to
assess compliance. Follow-up times vary widely
according to the patient’s age, risk factors, and history.
Additional evaluations are necessary if symptoms persist
or worsen, perhaps because of resistant bacteria or poor
antimicrobial coverage. Children should be considered at
greater risk for recurrence if they are younger than 6
months of age, attend day care, live with a smoker, or
have a history of multiple upper respiratory tract infection.
Antihistamines should not be used routinely in acute
bacterial sinusitis. They may dry nasal and sinus
secretions and thereby limit mucus clearance from the
sinus cavity. Antihistaminic therapy should be considered
when there are signs and symptoms that suggest an
allergic history. Nasal steroids theoretically alter the
inflammatory response in rhinosinusitis and decrease
edema and obstruction. These agents are not
unequivocally effective and are therefore not routinely
recommended in the treatment of acute sinusitis,
although they may have some benefits in chronic disease
(Wald et al., 1981).
CONCLUSION
Sinusitis was considered untreatable disease in the past
and patients had to live with sinusitis. Now a days
sinusitis can be easily diagnosed and treated because of
technological advances in nasal endoscopy and X-ray
imaging and enormous improvements in our
understanding of sinus and nasal problems. In this article,
we have discussed the diagnosis and treatment
strategies for sinusitis.
Khan et al. 5657
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